Long-term radiographic and clinical-functional outcomes of isolated, displaced, closed talar neck and body fractures treated by ORIF: the timing of surgical management

Background: The main purpose of this retrospective case series study was to evaluate long-term radiographic and clinical outcomes of a consecutive series of patients diagnosed with isolated, displaced, closed talar neck or body fractures treated by open reduction and internal fixation (ORIF). Secondly, the aim was to verify the influence of the location of talar fractures on the outcomes, the prognostic value of the Hawkins sign, whether operative delays promote avascular necrosis (AVN) and if the fractures require emergent surgical management. Methods: From January 2007 to December 2012, at our institution, 31 patients underwent ORIF through the use of screws. On the basis of Inokuchi criteria, the injuries were divided between neck and body fractures, which were classified according to Hawkins and Sneppen, respectively. The patients included were divided into two groups in relation to fracture location and complexity. Radiographic assessment focused on reduction quality, bone healing, the Hawkins sign and post-traumatic arthritis (PTA) development. For the clinical evaluation, clinical-functional scores (AOFAS Ankle-Hindfoot Score; MFS; FFI-17; SF-36) and VAS were determined, and statistical analysis was performed. Results: 27 patients, 19 males and 8 females, mean age 38.3 years, were included with an average follow-up period of 83.2 months (range 49\u2013119). There were 9 neck and 19 body fractures; their reduction was anatomical or nearly anatomical in 22 cases, and all reached radiographic consolidation after a mean period of 3.4 months (range 1.7\u20137). The Hawkins sign was observed in 9 cases, in which necrosis did not develop. With a 0\u201311 day surgical timing interval, more than 60% of the patients obtained good or fair results with different scores, while 18 (66.7%) were completely satisfied (VAS: 9\u201310). The early complications included malunions (21.4%) and wound problems (25%); the late complications involved AVN (25%) and PTA (78.6%). Conclusions: Despite a high rate of long-term complications, satisfactory clinical results were achieved. Talar fracture location did not influence the outcomes, the Hawkins sign was confirmed as a positive prognostic factor, and operation timing did not influence AVN development. Hence, these injuries do not require emergent surgical management by ORIF

Medium-Long-Term Radiographic and Clinical Outcomes after Surgical Treatment of Intra-Articular Tibial Pilon Fractures by Three Different Techniques

The goal of this retrospective, observational, case series study was to evaluate the medium-long-term clinical and radiographic results of the three most common surgical osteosynthesis techniques used for the treatment of articular tibial pilon fractures: ORIF, MIPO, and EF. Materials and Methods. A consecutive series of patients with articular pilon fractures who underwent surgery at our institution were enrolled in this study. Fractures were classified according to the M\ufcller AO classification system. Overall outcomes took the following into account: radiographic quality of reduction, evaluated using Ovadia and Beals\u2019 criteria; clinical assessment, evaluated using the AOFAS questionnaire; and general health, evaluated with the SF36-v2 Health Survey. Results. A total of 94 articular pilon fractures (34 type 43-B and 60 43-C) were evaluated with a mean follow-up of 56.34 months (range 33\u2013101). The techniques used were ORIF, MIPO, and EF in 63 (67%), 17 (18.9%), and 14 cases (14.1%), respectively. According to Ovadia and Beals\u2019 criteria, good, fair, and poor results were reported in 61 (64.89%), 26 (27.66%), and 7 (7.45%) cases, respectively. The mean AOFAS score was 82.41 for MIPO, 79.83 for ORIF, and 50.57 for EF, respectively. Thirty-nine patients (41.49%) presented early and/or late complications. Conclusion. Satisfactory outcomes using the three different techniques were reported. In particular, the radiographic outcomes were inversely proportional to the fracture comminutions and statistically different between internal and external osteosynthesis, but comparable between ORIF and MIPO techniques. On the other hand, the clinical outcomes were closely related to the soft tissue conditions and the anatomical reconstruction of the joint

Medium-Long-Term Clinical and Radiographic Outcomes of Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) for Central Primary Metatarsalgia: Do Maestro Criteria Have a Predictive Value in the Preoperative Planning for This Percutaneous Technique?

The purpose of this prospective study was first to evaluate the safety and effectiveness of Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) in treating central metatarsalgia, identifying possible contraindications. The second objective was to verify the potential of DMMO to restore a harmonious forefoot morphotype according to Maestro criteria. Methods. A consecutive series of patients with metatarsalgia was consecutively enrolled and treated by DMMO. According to Maestro criteria, preoperative planning was carried out by both clinical and radiological assessment. Patient demographic data, AOFAS scores, 17-FFI, MOXFQ, SF-36, VAS, and complications were recorded. Maestro parameters, relative morphotypes, and bone callus formation were assessed. Statistical analysis was carried out (p<0.05). Results. Ninety-three patients (93 feet) with a mean age of 62.4 (31-87) years were evaluated. At mean follow-up of 58.7 (36-96) months, all of the clinical scores improved significantly (p<0.0001). Most of the osteotomies (76.3%) had healed by 3-month follow-up, while ideal harmonious morphotype was restored only in a few feet (3.2%). Clinical and radiological outcomes were not different based on principal demographic parameters. Long-term complications were recorded in 12 cases (12.9%). Conclusion. DMMO is a safe and effective method for the treatment of metatarsalgia. Although Maestro criteria were useful to calculate the metatarsal bones to be shortened and a significant clinical improvement of all scores was achieved, the ideal harmonious morphotype was restored only in a few feet. Hence, our data show that Maestro criteria did not have a predictive value in clinical outcomes of DMM

Genetical stability and osteogenic ability of mesenchimal stem cells on demineralized bone matrices

Journal of Osseointegration Volume 7, Issue 1, 1 March 2015, Pages 2-7 Open Access Genetical stability and osteogenic ability of mesenchimal stem cells on demineralized bone matrices (Article) Pozzuoli, A.a, Gardin, C.b, Aldegheri, R.a, Bressan, E.c, Isola, M.d, Calvo-Guirado, J.L.e, Biz, C.a, Arrigoni, P.a, Feroni, L.b, Zavan, B.b a Department of Surgical,Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy b Department of Biomedical Sciences, University of Padua, Padua, Italy c Department of Neurosciences, University of Padua, Padua, Italy d Department of Animal Medicine, Production and Health (MAPS), Italy e Department of General Dentistry, Faculty of Medicine and Dentistry, University of Murcia, Murcia, Spain Hide additional affiliations View references (44) Abstract Aim: Tissue engineering is a rapidly expanding field with regard to the use of biomaterials and stem cells in the orthopedic surgery. Many experimental studies have been done to understand the best characteristics of cells, materials and laboratory methods for safe clinical applications. The aim of this study was to compare the ability of 2 different human demineralized bone matrices (DBMs), the one enriched and the other not enriched with hyaluronic acid, to stimulate in vitro the proliferation and the osteogenic differentiation of human adipose-derived stem cells (ADSCs) seeded onto an osteoconductive scaffold. Materials and Methods: ADSCs were isolated, by enzymatic digestion, from abdominal adipose tissue of 5 patients undergoing cosmetic lipoaspiration surgery. ADSCs were then seeded onto a 3D scaffold in the presence of the two different osteoinductive matrices of human demineralized bone and evaluated for proliferation and osteogenic differentiation. The safety of the methods was verified using array-Comparative Genomic Hybridization (array-CGH). Results: ADSCs were able to differentiate in osteogenic sense. Both DBMs showed the ability to induce osteogenic differentiation of the cells. Conclusion: array-CGH showed no changes at genome level, thus confirming the safety of materials and method

Functional outcome and complications after treatment of comminuted tibial fractures or deformities using Ilizarov bone transport: a single-center study at 15- to 30-year follow-up

Introduction - The aim of this retrospective study was to evaluate long-term outcomes and complications of a single-center and single-surgeon patient series of isolated and comminuted tibial fractures with bone defects or tibial deformities treated by Ilizarov bone transport. Materials and methods - Data from a consecutive series of patients with isolated comminuted tibial fractures (Fracture Group: FG) or deformities (Deformity Group: DG) treated between 1987 and 2002 were included. For clinical assessment, the Lower Extremities Functional Scale was used; complications were recorded according to the Dindo classification and statistical analysis was performed. Results - Overall, 72 patients were enrolled with a mean follow-up of 21.6 years (range 15\u201330) a mean LEFS of 36.4 (range 0\u2013100). In the FG, the mean LEFS was 21.3 (range 0\u201398.75), and the external fixation time (EFT) lasted 7.6 months (range 3\u201318 months) months. In the DG, the mean LEFS was 76.7 (range 55\u2013100), and the EFT was 10.6 months (range 3\u201320 months). Between the two groups, the clinical evaluation was significantly different, while the EFT was not (p = 0.14). In the FG, the worst results were obtained in the cases of open fractures with a higher percentage of complications and the need for further surgical procedures. The cumulative rate of complications was 55.6% during the first 36 months and 66.7% at the minimum follow-up of 180 months. Conclusions - Ilizarov bone transport, even at a long follow-up period, proved to be an effective technique for both definitive treatment of comminuted tibial fractures with bone defects or tibial deformities. Although our functional outcomes were lower in patients with exposed fractures, they were in line with the literature, but not influenced by the EFT when properly managed. Most complications occurred during the first 3 years; however, they could also arise much later, even until almost 30 years

Palliative embolization arteries or veins for a recurrent pelvic chondrosarcoma

Chondrosarcoma is a malignant bone tumor characterized by the formation of cartilage structures of varying degrees of ma-turity. They account for approximately 20 % of malignant skele-tal tumors. Chondrosarcoma most often affects the pelvis (iliac bone), the proximal femur and humerus, ribs. The chondrosar-coma of the pelvis has a low response to chemo- and radiation therapy, so they are usually resected by standard hemipelvec-tomy. New surgical reconstructive techniques allow surgeons to perform major reconstructions, thereby improving patients' quality of life. Clinical case: male, 64 years old, with complains of the left thigh pain for 6 months. The patient was made a com-prehensive examination \u2014 standard X-rays, MRI and CT scan of the pelvis, biopsy of the pathological formation. Diagnosis: chondrosarcoma II clinical group, stage IIB. Primary sur-gery \u2014 wide-field excision and reconstruction with a massive bone allograft was performed and bipolar hip replacement. Two major local recurrences were detected in 3 years. Due to inef-ficiency of chemo- and radiation therapy, refusal of the patient from amputation, high degree of tumor vascularization, arterial embolization was applied. A selective study of both the medial and lateral femoral arteries was performed using a uroangio-graphic contrast medium. The achievement of complete devas-cularization of the greatest lesion was confirmed angiographi-cally. After 20 days due to partial revascularization, re-emboli-zation of the lateral circular femoral artery was made. The final embolization of all arterial branches that fed the tumor was performed after 3 months with acrylic (n-butyl 2-cyanoacrylate) glue for larger-sized vessels and microparticles of polyvinyl al-cohol (150\u2013 250 \u3bcm) for the smallest branches. Conclusion: em-bolization can be effectively used as a palliative treatment for highly vascularized pelvic chondrosarcoma. Key words: chond-rosarcoma, pelvis, embolization, palliative, polyvinyl alcohol microparticles

Conservative Versus Surgical Management of Elbow Medial Ulnar Collateral Ligament Injury: A Systematic Review

Objective: Several studies have been published regarding the treatment of medial ulnar collateral ligament (MUCL) injuries for professional overhead athletes. However, there is a paucity of data regarding non-professional athletes. The aim of this systematic review was to compare the rate of outcome scores and complications of conservative versus operative treatments both in non-professional athletes and in non-sport-related trauma patients with MUCL lesions. Methods: A systematic review of the published literature was performed by applying the PRISMA guidelines. A search was conducted using three databases: Medline, Science Direct, and Web of Science. The keywords used were \u201culnar collateral ligament injury,\u201d \u201celbow,\u201d \u201csurgery,\u201d and \u201cconservative treatment\u201d. Patients were divided into three groups: patients who underwent conservative treatment (C-group), surgical treatment (S-group), and surgery after a failed conservative treatment (C&S-group). Clinical outcomes were analyzed: Disability of Arm, Shoulder and Hand (DASH), Conway scale, Carson score, and Kerlan\u2013Jobe Orthopaedic Clinic score (KJOC). Results: A total of 15 studies were included, evaluating 513 patients. Although good and excellent outcomes were found for most patients during daily and/or sport activities, independently of the type of treatment, the C-group had better results. Excellent results were found in 98.8% of the C-group, in 88.1% of the S-group, and in 87.7% of the C&S-group. The complication rate in the C-group was statistically higher compared to the S and C&S groups (P < 0.001). However, its complication rate was higher with lower patient satisfaction. Conclusions: There is insufficient evidence to establish statistically significant differences in the effects of conservative versus surgical treatments on the functional outcomes of patients with MUCL lesions. However, a period of rehabilitation therapy and the functional request of the single injured subject are useful to discern which patients genuinely require MUCL surgical repair

Role of fasciae in Civinini-Morton’s neuroma

Civinini-Morton’s metatarsalgia is characterized by a swelling, known as “neuroma”, of the common digital plantar nerve (CDPN), which may cause extreme pain and disability. Microscopically, the affected nerve presents extensive concentric perineural fibrosis. It is considered an entrapment syndrome, due to the impingement of CDNP against the stiff deep transverse metatarsal ligament (DMTL). According to this hypothesis, some surgeons suggest neurolysis, by cutting the DMTL1, as a treatment, instead of generally performed neurectomy. Also some rehabilitation techniques affirm that modifying perineural connective tissue improves patients’ symptoms2. To better study the relationships of the nerve with DTML and deep fasciae of the foot we dissected 15 feet and analyzed 30 MRI. Data from dissections confirm that CDPN’s bifurcation in the second and third webspace is always distal to DTML. Proximal to the metatarsal heads, the nerve is encased by a sheath made by concentric sleeves of fibrous and loose connective tissue continuous with vascular sheaths and deep fasciae of the foot: this arrangement, similar to a “telescope”, may provide a channel to allow the nerve to move independently from surrounding structures, being protected against traction during walking. In the intermetatarsal space, fascial septa connect DMTL, tendon sheaths and plantar fascia, and bound lobules of adipose tissue, more abundant on plantar aspect of the neurovascular bundle: these, along with adipocytes contained between concentric layers of neural sheath, could cushion compressive stresses. Distally to DMTL this protective system is less represented. MRI shows marked inter-individual morphologic variation of the intermetatarsal channel: its size varies from 16.22 mm2 to 64.43 mm2, with a mean value of 37.34 mm2. Its shape ranges from oval or rounded (with a big distance between DMTL and plantar fascia) to roughly rectangular (with a narrow distance); in some people the channel is filled with adipose tissue, while in others fibrous tissue prevails. Fascial septa also vary among people, ranging from barely discernible to 1.2 mm thick, while DMTL is relatively constant (from 0.5 mm to 1.0 mm thick). Plantar fascia varies from 0.6 to 1.1 mm. People who lack an efficient “sliding and cushioning system” could tolerate less mechanical stresses during walking and thus be at increased risk of Civinini-Morton’s syndrome. Perineural scarring (which forms the neuroma) consequent to nerve impingement could, by destroying neural sheath’s structure, further impair nerve protection and worsen symptoms

Prevalence of chronic pain syndrome in patients who have undergone hallux valgus percutaneous surgery: a comparison of sciatic-femoral and ankle regional ultrasound-guided nerve blocks

Background: Chronic pain syndrome (CPS) is a common complication after operative procedures, and only a few studies have focused on the evaluation of CPS in foot-forefoot surgery and specifcally on HV percutaneous correc‑ tion. The objective of this study was to compare postoperative pain levels and incidence of CPS in two groups of patients having undergone femoral-sciatic nerve block or ankle block regional anaesthesia before hallux valgus (HV) percutaneous surgery and the association between postoperative pain levels and risk factors between these patient groups. Methods: A consecutive patient series was enrolled and evaluated prospectively at 7 days, 1, 3 and 6 months after surgery. The participants were divided into two groups according to the regional anaesthesia received, femoral-sciatic nerve block or ankle block, and their outcomes were compared. The parameters assessed were postoperative pain at rest and during movement by the numerical rating scale (NRS), patient satisfaction using the Visual Analogue Scale (VAS), quality of life and return to daily activities. Statistical analysis was performed. Results: One hundred fifty-five patients were assessed, 127 females and 28 males. Pain at rest (p 0.05), quality of life significantly increased and patients returned to daily activities and work (p < 0.0001). No significant impact of type of anaesthesia could be detected. ASA 3 (p = 0.043) was associated to higher pain during movement; BMI (p = 0.005) and lumbago (p = 0.004) to lower satisfaction. No operative-anaesthetic complications were recorded. Postoperative pain at rest and during movement improved over time independently of the regional block used, with low incidence of CPS at last follow-up. Among risk factors, only a higher ASA was associated to higher pain during movement, while higher BMI and lumbago to lower satisfaction. Conclusions: Both ultrasound-guided sciatic-femoral and ankle blocks were safe and effective in reducing postoperative pain with low incidence of CPS at last follow-up

Anatomical-radiological study of the plantar fascia and its correlation with Achilles tendon pathologies

Although the plantar fascia (PF) has been studied quite well from a biomechanical viewpoint [1], nothing is known about its content of elastic fibers, the features of the extracellular matrix or the extent of innervation. From a functional and clinical standpoint, the PF is often correlated with the triceps surae muscle, but the anatomical grounds for this link are not clear. Twelve feet from frozen human cadavers were dissected to isolate the PF. Specimens from each PF were tested with various histological and immunohistochemical stains. 52 MRI obtained in patients complaining of non-specific ankle or foot pain were analyzed. The thickness of PF and paratenon was assessed and statistical analyses were conducted. The PF is a tissue firmly joined to plantar muscles and is closely connected to the paratenon of Achilles tendon through the periosteum of the heel. The PF was rich in hyaluronan, probably produced by fibroblastic-like cells described as “fasciacytes” [2]. Nerve endings and Pacini and Ruffini corpuscles were present, particularly in the medial and lateral portions, and on the surface of the muscles, suggesting a role for the PF in the proprioception of foot. In the radiological study, 27 of the 52 MRI showed signs of Achilles tendon inflammation and/or degeneration, and the PF was 3.43 ± 0.48 mm thick, as opposed to 2.09 ± 0.24 mm in the cases in which the MRI revealed no Achilles tendon diseases (p&lt;0.001). In the group of 27/52 cases with tendinopathies, the PF was more than 4.5 mm thick in 5, i.e. they exceeded the threshold for a diagnosis of plantar fasciitis. None of the other 25/52 cases had a PF more than 4 mm thick. There was a statistically significant correlation between the thicknesses of the PF and the paratenon. These findings suggests that the plantar fascia has a role not only in supporting the longitudinal arch of the foot, but also in its proprioception and peripheral motor coordination. Its relationship with the paratenon of the Achilles tendon is consistent with the idea of triceps surae structures being involved in the PF pathology, so their rehabilitation can be considered appropriate. Finally, the high concentration of hyaluronan in the PF points to the feasibility of using hyaluronan injections in the fascia to treat plantar fasciitis